Provider Demographics
NPI:1619066990
Name:BRYANT, THERESA JOHNSON (MA/LPC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:JOHNSON
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MA/LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 N THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8816
Mailing Address - Country:US
Mailing Address - Phone:989-781-0471
Mailing Address - Fax:
Practice Address - Street 1:2603 W WACKERLY ST
Practice Address - Street 2:SUITE, A
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6903
Practice Address - Country:US
Practice Address - Phone:989-631-2320
Practice Address - Fax:989-631-9903
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006769101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health